Impact of Delayed Gastric Emptying on the Outcome of Antireflux Surgery (original) (raw)
Related papers
Preoperative liquid gastric emptying rate does not predict outcome after fundoplication
Journal of Pediatric Surgery, 2017
Aim of the study: Preoperative gastric emptying (GE) rate in patients with gastrointestinal reflux disease (GERD) was evaluated as a predictor of outcome after antireflux surgery. Methods and patients: GE was assessed using radionuclide scintigraphy and a standardized meal with cow's milk. GE half time (T1/2), patient demographics and GERD symptoms including vomiting (N4 days/week), retching (N 4 days/week), prolonged feeding time (N 3 h/day), and discomfort after meals were recorded pre-and postoperatively. A standardized follow-up included a 24-h pH-monitoring and an upper gastrointestinal contrast study. Of 74 patients undergoing Nissen fundoplication between 2003 and 2009, 35 underwent a preoperative GE study. The remaining 39 patients were not examined owing to volume intolerance, cow's milk intolerance or allergy, inability to lie still, or parents refusing participation. Main results: Median age at fundoplication was 4.9 [range 1.1-15.4] years, and follow-up time was median 4.3 [1.9-8.9] years. GERD recurred in 7 (20%) patients. Preoperative T1/2 in the seven patients with recurrent GERD was median 45 [21-87] min compared to 44 [16-121] min in the 28 patients without recurrent GERD (p = 0.92). There was no significant difference between the one third of patients with the slowest GE [T1/2 54-121 min] and the remaining patients [T1/2 16-49 min] regarding GERD recurrence or postoperative vomiting, retching, prolonged feeding time, or discomfort after meals. Conclusion: Preoperative GE rate did not predict outcome after antireflux surgery, as slow GE was not associated with recurrent GERD or postoperative troublesome symptoms such as vomiting, retching, or meal discomfort.
Annals of Surgery, 1989
Delayed gastric emptying in patients with gastroesophageal reflux disease may be due to an incompetent distal esophageal sphincter and/or a gastric abnormality. To determine the influence of the Nissen fundoplication on gastric emptying we studied the rate of gastric emptying before and after operation in 25 patients with proved gastroesophageal reflux disease. Nine patients had no gastric pathology, 9 had gastric acid hypersecretion, 5 had gastritis, and 2 had evidence of significant duodenogastric reflux. All were treated by Nissen fundoplication. Those with gastric acid hypersecretion also had a proximal gastric vagotomy (PGV) and the two patients with pathologic duodenogastric reflux were treated by a bile diversion procedure. We found that in gastroesophageal reflux disease with associated gastric pathology there was a higher prevalence of delayed gastric emptying before operation than in patients without gastric pathology. Nissen fundoplication was associated with speeding of gastric emptying in patients with or without gastric pathology. Proximal gastric vagotomy performed in association with Nissen fundoplication augmented the speeding of gastric emptying, which was advantageous in most cases but detrimental in two. Every patient in whom gastric emptying was not normalized had postoperative symptoms. Only two of 20 patients with normal postoperative gastric emptying had postoperative symptoms. Both patients had preexisting gastric pathology. Based on these findings, the side effects associated with Nissen fundoplication are due to the failure to normalize gastric emptying rather than the operation. T^WO THIRDS OF PATIENTS with foregut symptoms such as heartburn, regurgitation, dysphagia, cough, chest pain, or epigastric pain have increased esophageal exposure to gastric juice and one half have abnormal gastric emptying. When these are present they occur separately or together so that 41% of patients have increased esophageal acid exposure alone, 19% have abnormal gastric emptying alone, and 40% have both.' This suggests that an incompetent distal esophageal
Gastric emptying and antireflux surgery
Pediatric Surgery International, 2011
Purpose Absence of consistent data on the outcome of gastric emptying after fundoplication raises concerns about preoperative workup and surgical management. This study assessed how gastric emptying evolves after isolated fundoplication in order to determine whether a preoperative investigation and/or a concurrent gastric drainage procedure are justified. Methods Eleven children with GERD underwent both pre- and post-operative gastric emptying scintigraphy. No gastric
World journal of surgery, 2013
There are no prospective studies available on the behavior of extraesophageal and esophageal symptoms and treatment-related side effects in patients without effective antireflux medication, receiving the most effective antireflux medication, and after laparoscopic fundoplication. Extraesophageal and esophageal reflux symptoms and treatment-related side effects were assessed in 60 patients while they were on no effective antireflux medication (three-week washout period), after three month of treatment with double-dose esomeprazole, and 3 months after laparoscopic Nissen fundoplication. Esophageal and extraesophageal reflux symptoms, rectal flatulence, and bloating were analyzed with the visual analog scale. In addition, dysphagia, rectal flatulence, and bloating were recorded as none, mild, moderate, or severe. Both extraesophageal and esophageal reflux symptoms decreased after treatment with esomeprazole and were further reduced after fundoplication. Dysphagia and flatulence did not...
Gastroenterology, 2001
Recent studies have shown that many patients use acid suppression medications after antireflux surgery. The aim of this study was to determine the frequency of gastroesophageal reflux disease in a cohort of surgically treated patients with postoperative symptoms and a high prevalence of acid suppression medication use. The study group consisted of 86 patients who had symptoms following Nissen fundoplication that were sufficient to merit evaluation with 24-hour distal esophageal pH monitoring. All completed a detailed symptom questionnaire. The mean postoperative follow-up period was 28 months (median 18 months). Thirty-seven patients (43%) were taking acid suppression medications after fundoplication. Only 23% (20 of 86) of all the patients and only 24% (9 of 37) of those taking acid suppression medications had abnormal esophageal acid exposure on the 24-hour pH study. Heartburn and regurgitation were the only symptoms that were significantly associated with an abnormal pH study. Endoscopic assessment of the fundoplication was the most significant factor associated with an abnormal pH study. Multivariable logistic regression analysis showed that patients with a disrupted, abnormally positioned fundoplication had a 52.6 times increased risk of abnormal esophageal acid exposure. Most patients who use acid suppression medications after antireflux surgery do not have abnormal esophageal acid exposure, and the use of these medications is thus often inappropriate. Because of the limited predictive power of symptoms, objective evidence of reflux disease should be obtained before prescribing acid suppression medication for patients who have undergone antireflux surgery. ( J G ASTROINTEST S URG 2002;6:3-10.)
Clinics, 2012
A 46-year-old white woman presented to the clinic in September 2009 with intermittent abdominal epigastric pain accompanied by nausea, heartburn and frequent crises of asthma and cough for one year. Her past medical history revealed obesity-related arthropathy and a lumbar discal hernia with chronic NSAID use and no history of smoking. She underwent laparoscopic Roux-en-Y gastric bypass (RYGB) in September 2004 for morbid obesity (body mass index (BMI) 41.02 kg/m 2 ) to construct a vertically oriented proximal gastric pouch, with a 120-cm jejunal Roux limb and jejunojejunostomy 50 cm beyond the ligament of Treitz (Figure1A-E). The gastric pouch was 3.5 cm, and the manually performed gastrojejunostomy was 13 mm, as verified by routine endoscopy one year after the operation . A routine pre-operative upper endoscopy prior to the RYGB was normal. Two years after the RYGB, she was also submitted to laparoscopic adhesiolysis for small bowel obstruction. In September 2009, her weight decreased to 75.6 kg (166.3 lbs), which corresponded to a BMI of 26.79 (28% weight loss). Abdominal ultrasound and computed tomography ruled out any pancreatic or hepatobiliary disease. As the patient's symptoms did not improve despite extended trials of antacids and double doses of proton-pump inhibitors for over a year, investigations with 24-h esophageal pH monitoring (24h pH testing) and manometry were conducted. A new upper endoscopy post-RYGB revealed a patent gastrojejunostomy ) in addition to grade B Los Angeles reflux esophagitis, with 10-mm longitudinal mucosal breaks ( ) and no signs of eosinophilic esophagitis. There was no evidence of hiatal herniation or Barrett's esophagus. Based on a 24-h pH test performed prior to fundoplication, the DeMeester score was 67.8 mmHg, with acid reflux occurring greater than 10% of the time both in supine (42.3%) and upright (16.9%) positions. The DeMeester reflux score was 67.8 (normal ,14.72, 95th percentile). Manometry showed a lower esophageal sphincter pressure (LES) of 9 mmHg (normal range from 14.3 to 34.5 mmHg), and the contraction amplitude of the proximal and middle region was greater than 30 mmHg (50.6 mmHg). A biopsy showed grade 2 esophagitis. The upper gastrointestinal (GI) series revealed proper emptying of the gastric pouch but free gastroesophageal reflux disease (GERD). Therefore, the management of intractable postoperative reflux was performed with a laparoscopic 360f undoplication to reinforce the lower esophageal sphincter by wrapping the excluded stomach around the lowest portion of the esophagus. This technique has not been previously described. Hiatal dissection and repair were performed, and the crura were approximated with three interrupted 2.0 polypropylene sutures. The excluded stomach was carefully isolated and used to construct the fundoplication, and the short gastric vessels were divided using the harmonic scalpel from the inferior pole of the spleen to the superior aspect of the excluded stomach. A loose, short 3-cm wrap was constructed, with assessment of the z-line ( ) performed under endoscopic guidance ( . A 32-Fr intra-esophageal bougie was also used to calibrate the wrap. The excluded stomach (approximately 6 cm) was passed behind the esophagus, and the anterior and posterior excluded stomach lips were sutured together with three interrupted 3.0 polypropylene sutures ( ). The muscular wall of the anterior esophagus was incorporated in the sutures while carefully avoiding injury to the anterior vagus nerve. The fundoplication was not anchored to the crura. Reflux symptoms were scored using the Visick classification and a validated GERD questionnaire published elsewhere (1) before and after fundoplication (six months post-operation). There was marked improvement of preoperative symptoms and well-being in the post-operatory period (change in Visick classification from 3 to 1 and change in reflux symptoms score from 33 to 2). The patient tolerated the operation with no complications and experienced successful resolution of GERD symptoms. She was discharged on postoperative day two, tolerating a liquid diet without reflux or dysphagia. We were able to compare 24-h pH testing and manometry pre-and post-operatively. The erosion near the gastrojejunostomy ( ) healed after the surgery. She continues to be asymptomatic without reflux or dysphagia six months later.